NSQHS Standards updates and consultations

In 2020, health service organisations had 12 months added to their current accreditation expiry date. This means whatever month and year your current accreditation was due to expire, it now expires in that month, one year later.

Your assessment should be scheduled with your accrediting agency to commence at least four months before your revised accreditation expires.

On-site assessments are occurring where the risk of transmission of COVID-19 is being well managed. On-site assessments can generally proceed in health service organisations where:

• Patients with active COVID-19 are not being treated The health service organisation does not have (or does not suspect they have) a member of the workforce with COVID-19 which could have been transmitted to others in the organisation
• The health service organisation is fully vaccinated
• There is limited impact on the normal workforce being available for duty. Members of the workforce are not
  • In isolation due to possible or confirmed COVID-19 contact
  • Redeployed to support COVID-19 related activities within or across health service organisations
• The health service organisation is not directly affected by
  • A public order that has resulted in a lockdown or restriction of movement of citizens
  • Known active COVID-19 infections in the area
• The organisation is not supporting an aged care facility with active COVID-19 infections.

Health service organisations that have a scheduled on-site assessment that cannot proceed because of the risk of transmission of COVID-19, may seek approval for virtual or hybrid assessment modes or a maintenance of their accreditation expiry date.

When scheduling assessments, the Commission has asked accrediting agencies to prioritise:

• Organisations that have completed an initial assessment and are awaiting a final assessment to address any actions that were not met and required remediation
• Organisations that were previously scheduled for assessments from March 2020 and have not yet been assessed.

Your assessment should be scheduled at least four months before the revised accreditation expiry date.

Organisations that have completed an interim assessment when operations were first commenced, are required to complete a full assessment to the NSQHS Standards within an 18 month period. This requirement is unchanged for organisations that are assessed as low risk for the transmission of COVID-19.

However, if an organisation that has undertaken an interim assessment is not a low risk health service, interim accreditation will be maintained until an on-site assessment can be conducted.

The Commission has been working with accrediting agencies to ensure on-site assessments are as safe as possible for patients, the workforce and assessors. Before entering your organisation, assessors must have:

• Completed additional infection prevention and control training
• Passed a screening checklist to ensure they have no signs or symptoms of a respiratory infection

Assessors are required to comply with any screening requirements put in place by the organisation they are visiting.

All health service organisations accredited to the NSQHS Standards have had an additional 12 months added to their current accreditation expiry date. This administrative action will be performed by the Commission and accrediting agencies. Amended certificates have not been reissued by accrediting agencies, however health service organisations seeking formal notification can request a statement of revised accreditation details from their accrediting agency.

Enquiries please email the Advice Centre: accreditation@safetyandquality.gov.au or contact your accrediting agency.

Newly established health service organisations must undergo interim accreditation and be assessed within 10 working days from the commencement of service provision as described within NSQHS Standards Advisory AS18/02.

Where it is not possible for the assessment team to perform the final interim assessment on site due to COVID-19 restrictions or public health orders, the accrediting agency may apply to the Commission to perform a hybrid or virtual assessment.

Organisations that have completed an interim assessment when operations were first commenced, are required to complete a full assessment to the NSQHS Standards within an 18 month period. This requirement is unchanged for organisations that are assessed as low risk for the transmission of COVID-19.

However, if an organisation that has undertaken an interim assessment is not a low risk health service, interim accreditation may be extended until an on-site assessment can be conducted.

Where it is not possible for the assessment team to perform the final interim assessment on site due to public health orders or COVID-19 related restrictions, the accrediting agency may apply to the Commission to perform a hybrid or virtual assessment.

Where a health service organisation has undergone final interim assessment via the hybrid method and has met the requirements to be accredited, the accrediting agency may issue an accreditation certificate.

Where an assessment was solely conducted virtually, a subsequent on-site assessment must be conducted as soon as practicable thereafter to meet the requirements of a hybrid assessment.

If actions are found to be “not met” during the subsequent on-site assessment, the interim accreditation will be withdrawn and remediation processes instigated. 

If an organisation has actions which are not met at the final interim on-site assessment, there is a remediation period in which they must demonstrate sufficient change has been implemented for actions to be rated met or met with recommendations and to be awarded accreditation.